Silva PD, Perkins HE
Gundersen Clinic, 1836 South Avenue, La Crosse, WI 54601.
J Am Assoc Gynecol Laparosc. 1994 Aug;1(4, Part 2):S33-4. doi: 10.1016/s1074-3804(05)80978-8.
In a previous study of outpatient reversal of tubal sterilization by a combined approach of laparoscopy and minilaparotomy, postoperative intrauterine pregnancy rates were 71%, and total costs were 40% lower than for those women undergoing anastomosis by a traditional laparotomy. However, the technique, which involved exteriorization of the uterus and adnexa, could not be easily applied when difficult cases with little remaining oviduct were encountered. With a modification of technique and the addition of a new retractor, it became feasible to consider more difficult cases for minilaparotomy outpatient reversal of sterilization. We prospectively studied 11 such patients with weight < IBW + 30% and < 4 cm of operable oviduct for technical feasibility, cost, complication rates, and reproductive outcome. A vaginal pack was used to elevate the uterus and a Babcock clamp was used to bring the fundus toward the incision by traction on the round ligament. A small self-retaining retractor designed for back surgery (Cloward retractor) was used for the abdominal wall. With the aid of an operating microscope a two-layer anastomosis was performed with 7-0 and 9-0 polydiaxone sutures. In all cases minilaparotomy reversal of tubal sterilization could be performed without prolonged technical difficulty. The mean age of the patients was 34.1 years (range 25-41 years) and operating time 110 minutes (87-158 min). There were no intraoperative or perioperative complications during the same day hospitalization. The mean time of follow-up was 16.7 months. Postoperatively, five women had ongoing or delivered pregnancies (45%) and one woman had two ectopic pregnancies. This study demonstrated a method for outpatient reversal of extensive tubal sterilization which was technically feasible in the 11 attempted patients. Based on the preliminary data from this study we encourage patients who have had extensive tubal sterilization procedures to consider both outpatient, minilaparotomy anastomosis and IVF as reasonable alternatives.
在先前一项关于通过腹腔镜检查和小切口剖腹术联合方法进行输卵管绝育术门诊逆转的研究中，术后宫内妊娠率为71%，总成本比接受传统剖腹吻合术的女性低40%。然而，该技术涉及子宫和附件的外置，当遇到剩余输卵管很少的困难病例时，不容易应用。通过技术改进并增加一种新的牵开器，对于小切口剖腹术门诊输卵管绝育术逆转而言，考虑更困难的病例变得可行。我们前瞻性地研究了11例体重<理想体重+30%且可操作输卵管<4厘米的此类患者，以评估技术可行性、成本、并发症发生率和生殖结局。使用阴道填塞物抬高子宫，通过牵拉圆韧带使用巴布科克钳将子宫底拉向切口。一种为背部手术设计的小型自动牵开器（克洛德牵开器）用于腹壁。在手术显微镜的辅助下，用7-0和9-0聚二氧杂环己酮缝线进行两层吻合。在所有病例中，小切口剖腹术输卵管绝育术逆转均能顺利进行，未出现长时间的技术难题。患者的平均年龄为34.1岁（范围25 - 41岁），手术时间为110分钟（87 - 158分钟）。在当日住院期间未出现术中或围手术期并发症。平均随访时间为16.7个月。术后，5名女性有持续妊娠或分娩（45%），1名女性有两次异位妊娠。本研究展示了一种用于广泛输卵管绝育术门诊逆转的方法，在11例受试患者中技术上是可行的。基于本研究的初步数据，我们鼓励接受过广泛输卵管绝育术的患者将门诊小切口剖腹吻合术和体外受精均视为合理的替代方案。
